Using HTML5 as the basis for HL7 CDA v3

Keith Boone, well known and liked Health IT standards geek has written up a proposal that would make the next release of HL7 CDA based on HTML5 rather than XHTML.

I have just become more deeply familiar with this set of standards as the result of the extensive research I have done on my new book on meaningful use  of Health IT.

I can say, without a moment of hesitation, that this is a really good idea.

Everyone should support this proposal, b/c otherwise, CDA is a huge mess.

Which is not to say that an HTML5 version would not also be a huge mess. But I believe that it would be less of one.


Sharks, Bees and Privacy


I am happy to announce that my new article on healthcare privacy and interoperability has been accepted in the Journal of Participatory Medicine.

I am not against privacy in healthcare, but I am against the notion that privacy concerns should trump issues relating to good healthcare.

You can read the full article here:


Google Health: influential, controversial and gone.

Google Health is no more.

Thats a shame, because I am writing a book on Health IT for O’Reilly and before this announcement, my rough draft featured Google Health extensively.

I guess this is better, though, than having Google Health shut down just -after- I finished writing my book.

Of course, I am going to have to change lots of content in the book, but Google Health will still be there.

For a project that no longer exists, it will end up being one of the most influential Health IT projects of our era. Google Health, and for that matter Google generally, has always been willing to make strong statements when they evaluate technology and technology protocols. In fact, Google has made two controversial technology picks and the opening and closing of Google Health.

At the opening Google decided that they would support CCR (Continuity of Care Record) from ASTM and AFFP rather than the much more complex CDA/CCD from HL7. The CCR vs CCD debate has been one of the most controversial and long-standing arguments in Health IT. HealthVault, the Microsoft product which survives Google Health has always elected to support both standards. But Google insisted that the CCD standard was too complex, and not only insisted on CCR, but a smaller subset of that standard.

Now, as the end support for Google Health, Google is choosing to allow export under the Direct Protocol. Again this is the simpler of the two protocols that is supported by ONC to be part of the NWHIN (the precursor to the Health Internet). The other protocol, IHE, is getting no love from Google Health.

Goodbye Google Health, whatever else I may have said about you, I must admit that you made some ballsy technical stands.


EHR can make the paper problem worse

Once a persons record has gone electronic, it really should never go back.

A paper printout of an Electronic Health Record is often huge and unwieldy. If it is printed out or faxed it creates something so huge that it is pretty impossible to be useful in a paper record.

This is the reason why need electronic interoperability solutions like the Direct Project. Without it, when a patient leaves one doctor, they have to print out an electronic record, take it to the next doctor, and then have that doctor scan the record in.

That doesn’t sound too bad until you realize that a patients printed EHR record often looks like this:

What happens when you print the contents of an EHR record for a single patient

This image was provided to me by Jodi Sperber and Dr. Eliza Shulman, who generously agreed to share the photo under a Creative Commons license. Here is the full description from Flickr, which provides greater context.

An example of why interoperability is as important as the electronic health record itself.

The story behind this photo: This is a printout of a patient’s medical record, sent from one office to another as the patient was changing primary care providers. An EHR was in place in both offices. Additionally, the EHR in both offices was created by the same vendor (a major vendor); each health organization had a customized version. Without base standards the systems are incompatible. Instead, the printouts had to be scanned into the new record, making them less searchable and less useful.

Note that this was not the entirety of the patient’s medical record… Just the first batch received.

Direct gathers steam

Recently, the AAFP and Surescripts announced Physicians Direct, a secure messaging service for providers.  But neither the article nor the signup page for Physicians Direct detail the most critical single issue regarding the service. This is a very large deployment of the Direct Project. This is by far the most important part of the story, but it is buried deep with the FAQs.

That means that the service is compatible with other large adopters of the Direct Protocol. Most notably, HealthVault has just launched a beta deployment of Direct.
Think of the implications of this. One of the largest PHR providers in the country is on the network, one of the largest network of doctors is on this network.

We are watching the birth of the Health Internet.. its is truly wonderful to be involved in this work.

When I tell my grandkids what I did with my life, I hope the links to my early posts on the Security and Trust Working Group of the Direct Project are still up. “I was part of that from the beginning” I will say… My previous plan was to tell them that I invented bubble-gum ice cream, and then enjoy basking in their amazed adoration, until they discovered that Grampa’s stories are “unreliable”.

This will work out much better.

This is also a tremendous step for Surescripts away from being a proprietary network provider. For those who are unfamiliar with Health IT, Surescripts has a monopoly in e-prescribing after buying out its only competitor several years ago. If you e-prescribe in the United States, there is a 99% chance that the data cross the Surescripts network. Surescripts is free to use for Doctors, but the pharmacies pay for the privilege. But that business model will die as the Health Internet grows. Once the pharmacies realize that you can use the Health Internet to exchange prescriptions rather than the expensive Surescripts network, that business will dry up quickly. Moving into the Health Internet provider business is the only chance Surescripts has at long term survival. This is a very smart move for them.

Of course, this also has implications for meaningful use. Providers can use this exchange network, without making an expensive investment in EHR technology, and still qualify for part of the meaningful use dollars. $15 a month might seem expensive for glorified email, buts a whole lot cheaper than an EHR.


Kaiser Ontology Interview

To the novice, the term “interoperability” means that two systems can talk.

To the expert, it means that they can understand each other. To much of our current data interchange is “meaning poor”.

To get past that problem, we need to do lots of work with ontologies, which, loosely put, are knowledge dictionaries. Most clinicians in the US have no training in ontologies and their real-world experience is limited to billing ontologies like CPT and ICD. As a result, the value of proper coding is largely lost on the average clinician in the US. ( I wonder how this issue is understood by common clinicians outside the US…)

Those of us who obsess with the future of Health IT recognize that we need to find ways to make Ontologies more productive.

At this year’s health 2.0 conference, I caught up with Dr. John Mattison of Kaiser Permanente to discuss a tremendously important contribution that they are making to the Open Source Health IT community. I have already blogged about this significant ontology development from Kaiser. So I was really pleased to be able to get these kinds of details from the horses mouth. These details include that the license will be the Apache 2.0 license.

Part 1

Part 2

Health Internet

For whatever reason people simply do not get what the NHIN is and what its implications are.

This feels like a repeat of what happened to me more than a year ago.

The NHIN (which has been rebranded the “Nationwide Health Information Network” or NWHIN from “National Health Information Network” in response to these silly trademarks) is going to be the foundation of a new Health Internet. The US Government wisely will not call it that, because of the paranoid privacy histrionics that this would induce, but nonetheless it -is- a Health Internet. The definition of the word “Internet” is: Any set of computer networks that communicate using the Internet Protocol. The Internet, the largest global internet

The Health Internet by extension is the “largest Internet devoted to Healthcare Data”.

Here are the basic features of the Health Internet:

  • You will be able to ’email’ your doctor.
  • Your doctor will be able to ’email’ you.
  • Faxing health records will go away.
  • Eventually, your medical records will auto-magically follow you around the country, appearing when they are most needed in a moments notice.
  • All of this will be done securely and in a way that fully supports peoples legitimate need for privacy.
  • New innovative services will appear, that leverage the Health Internet data channel to create applications that were previously unthinkable.

How is this being accomplished? Simple as one two three:

  1. The EHR stimulus money will be given out in response to “meaningful use” standards which include interoperability requirements, which will require connecting and sharing data, without specifying a specific technology stack. These standards will become more and more pronounced as time moves forward.
  2. ONC is supporting the development of two Open Source projects that will serve as reference implementations of the two NHIN protocols: IHE and the newly formed Direct Protocol. Those projects are the IHE projects: (CONNECT Project if your are a federal agency and the Aurion Project if you are anyone else, updated 8-19-11) and the Direct Project (Direct). I recommend you watch this OSCON video for a basic explanation of these two projects.
  3. The Federal Government will expose its considerable health data resources (i.e. DoD and the VA) using these two protocols. Agencies which accept the reporting of meaningful use measures will accept that reporting using one or both of these two protocols.

So are these protocols being mandated? No. But then neither were HTTP, STMP, SSH, SSL, or DNS. Its just what everyone uses. The VA has the single largest pile of detailed health records in the history of mankind. They will be available using either CONNECT-complatible IHE or Direct-compatible Direct protocol. They will probably not be available using your-favorite vendors idea of a proprietary health data exchange protocol.

This is going to happen. Hell, it already is happening. These reference implementations are entirely Open Source. They are designed to eventually handle the cases of communicating across national boundaries. This is going to the start of a international Health Internet. First with Canada and Mexico, and nations promoting Medical Tourism and then everyone else. It will take time. Adoption might be slow. But there will be a Health Internet, it will use these protocols. It is only a question of how long this will take to be adopted, and how long it will take people to stop talking in the abstract about the issues of Health Data Exchange.

This is happening. Adjust.


MOSS crosses the threshold

MOSS has successfully tested the IHE profiles, all available under Open Source licenses.

I know for a fact that the MOSS team has been working on this for years. Completing these tests, and making sure they actually work at a Connectathon takes months of preparation and several frantic days of performance. In this respect, the Connecathon is something like a professional sporting event, one where you win by cooperating instead of competing.

This is an extremely impressive achievement and the MOSS team deserves applause. Because they are releasing most of these components as FOSS, the whole world is richer for their achievement!


Updated 2-21-09

Some have pointed out that not all of the Misys HIE tools are open source. This is quite true and I have updated the post to reflect that. MOSS makes no bones about being a hybrid proprietary/open source company.  I am sorry that I gave an impression to the contrary.